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The White House Initiative to Combat
AIDS: Learning from Uganda
by Joseph Loconte
Backgrounder #1692
September
29, 2003
http://www.heritage.org/Research/Africa/BG1692.cfm
Earlier this year, the Bush Administration persuaded Congress to
authorize $15 billion over the next five years to fight the AIDS
pandemic in Africa and the Caribbean. The U.S. Leadership Against
HIV/AIDS, Tuberculosis, and Malaria Act of 2003 is a bold legislative
effort.1 About 42 million people worldwide are dying of AIDS or are
infected with the HIV virus that causes the disease. Of these
individuals, 29 million live in Africa. In addition, Africa is home to a
staggering 11 million orphans who have lost their parents to AIDS.
These
facts carry political as well as moral implications: Failure to confront
the pandemic in nations ravaged by AIDS is a recipe for economic decline
and social chaos.
In the
legislation, Congress devotes 55 percent of the $15 billion to treating
individuals with HIV/AIDS, 15 percent to palliative care, and 10 percent
to organizations helping orphans and vulnerable children. The remaining
20 percent is for prevention programs: mother-to-child transmission
programs, clean syringes for medical injections, condom distribution,
and abstinence and monogamy programs. Although effective treatment
programs are essential to combating the AIDS virus, prevention is more
critical.
The ABC Model
The
Bush Administration is basing its AIDS initiative on the success of
Uganda, which has experienced the greatest decline in HIV prevalence of
any country in the world.2 Studies show that from 1991 to 2001, HIV
infection rates in Uganda declined from about 15 percent to 5 percent.
Among pregnant women in Kampala, the capital of Uganda, HIV prevalence
dropped from a high of approximately 30 percent to 10 percent over the
same period.3 How did Uganda do it?
The
best evidence suggests that the crucial factor was a national campaign
to discourage risky sexual behaviors that contribute to the spread of
the disease. Beginning in the mid-1980s, the Ugandan government, working
closely with community and faith-based organizations, delivered a
consistent AIDS prevention message: Abstain from sex until marriage, Be
faithful to your partner, or use Condoms if abstinence and fidelity are
not practiced.
The
link between Uganda's "ABC" approach and the dramatic reduction in the
country's HIV/AIDS rate is now widely acknowledged. Based on research
data collected over the past decade, several lessons can be drawn from
the success of Uganda's strategy:
-
High-risk sexual
behaviors can be discouraged and replaced by healthier lifestyles.
-
Abstinence and
marital fidelity appear to be the most important factors in preventing
the spread of HIV/AIDS.
-
Condoms do not
play the primary role in reducing HIV/AIDS transmission.
-
Religious
organizations are crucial participants in the fight against AIDS.
The
White House correctly insists on basing U.S. AIDS policy on these
lessons and the best available research about effective prevention and
treatment programs. "The Ugandan model has the most to teach the rest of
the world," says Edward Green, a senior research scientist at Harvard
and author of Rethinking AIDS Prevention. "This policy should guide the
development of programs in Africa and the Caribbean funded under the
President's initiative."4 Jeff Spieler, chief of the research division
in the U.S. Agency for International Development (USAID) population
office, states, "It just happens to be where the evidence is pointing."5
Congress should follow the evidence as well. Although it has approved
the President's initiative, Congress is still debating whether to follow
Uganda's ABC approach. Lawmakers should be guided by good data, not
ideology, in the upcoming appropriations and confirmation debates.
To
promote the most effective AIDS policy for developing nations, Congress
should:
-
Endorse
effective prevention policy by insisting that AIDS funding uphold the
ABC program emphasis on abstinence and marital fidelity;
-
Ensure
that programs for high-risk groups, such as commercial sex workers and
drug addicts, make rescue and recovery a major program goal;
-
Empower
non-governmental organizations (NGOs) while protecting their right to
fight AIDS without compromising their moral and religious beliefs;
-
Sharply limit
the U.S. contribution to international AIDS organizations until their
policies reflect the best AIDS prevention and treatment programs
available; and
-
Insist
that the
President's nominee for Global AIDS Coordinator fully endorse the ABC
prevention model.
The Success Of Uganda
The
President's AIDS initiative faces profound challenges. First, most of
the African continent lacks the health care infrastructure required to
treat HIV/AIDS and other deadly diseases effectively. Second, many
African governments are either unprepared to face their AIDS crisis
seriously or too corrupt and unaccountable to mount effective treatment
campaigns. Finally, international AIDS organizations and activists
continue to ignore the success of Uganda while promoting flawed
approaches to disease prevention. A recent Washington Post story about
Uganda, for example, quoted health care workers enthusiastic about
condoms but omitted any testimony from government health officials about
their emphasis on sexual abstinence and partner reduction.6
Science Speaks
Similar omissions of fact continue to appear in some research studies
and popular press accounts about Uganda's success. It is evident that
ideology, not good science, threatens to derail the White House
initiative and thwart efforts to redirect resources toward effective
AIDS prevention. New York Times columnist Nicholas Kristof, citing
prevention approaches that emphasize abstinence, calls it "baffling" to
see governments and the NGOs "buying into junk science in ways that will
lead to many more deaths."7
What
is truly baffling--and inexcusable--is how anyone concerned about
preventing AIDS can ignore the straightforward conclusions of virtually
every reputable survey and qualitative study of the Uganda experience.
Data supporting the effectiveness of the ABC approach have come from
USAID, the Joint United Nations Program on HIV/AIDS (UNAIDS), the World
Health Organization (WHO), the Harvard Center for Population and
Developmental Studies, the Ugandan government, and numerous independent
studies published in medical journals.
Despite different approaches, the reports all agree on at least one
central fact: Abstinence and reduction in the number of sexual partners,
not condoms, were the most important behavioral changes linked to HIV
prevalence decline in Uganda.
A
Global Leader
The
results in Uganda are both startling and unambiguous: Uganda's
Demographic and Health Survey of 2000-2001 found that 93 percent of
Ugandans changed their sexual behaviors to avoid AIDS.8 The U.S. Census
Bureau/UNAIDS estimates that Ugandan HIV prevalence peaked at about 15
percent in 1991 and fell to 5 percent as of 2001.9 As a 2002 USAID
report states, "This dramatic decline in prevalence is unique worldwide,
and has been the subject of...intense scientific scrutiny."10
Considering its limited financial resources, Uganda's success is even
more impressive. America spends about 40 times more per capita on AIDS
than Uganda spends on all its health care issues.11 Yet, in the United
States, the incidence of HIV/AIDS is again rising, prompting health
officials to warn of "a resurgent epidemic."12 The U.S. increase in HIV
infection rates comes despite aggressive marketing of condoms and
expensive anti-retroviral drugs--the treatment paradigm mostly ignored
by Uganda.
The Lessons of Uganda
How
exactly did Uganda achieve its results? President Yoweri Museveni came
to office in 1986 and quickly launched a frank and sobering education
campaign about the deadliness of the disease and the hazards of
irresponsible sex. It offered three clear options for avoiding death
from AIDS: The emphasis for the majority population was on monogamy. The
emphasis for youth was on abstinence. Condoms were offered as a last
resort, mostly for high-risk groups.
The
message was delivered from middle-school classrooms to churches to
community seminars and in radio, print, and television broadcasts. The
government established highly effective partnerships with the religious
community, working cooperatively to design and implement the ABC
program. The effect was to create what researchers call a "social
vaccine" against HIV: a set of cultural values that encouraged more
responsible sexual attitudes and behaviors.13
Based
on the best research data available, several lessons can be drawn from
Uganda's experience.
Lesson 1: High-risk sexual behaviors can be discouraged and replaced
with healthier lifestyles.
The
most significant changes in Uganda involved high-risk sexual behaviors.
One data set shows dramatic declines in the number of people engaging in
sex with multiple partners. Only 21 percent of Ugandan males reported
having more than one partner in 1995, down from a high of 41 percent in
1989. Among females, only 9 percent reported multiple partners.14
Ugandans embraced what they call "zero grazing," meaning being faithful
to one partner, typically in a marriage relationship. Faithfulness "was
the main message for the majority of Uganda's population," says Dr.
Green, a medical anthropologist with 30 years of experience in
developing countries. He adds that it was a message remarkably well
received: "Fidelity to one partner...seems to have been the main
response to the epidemic."15
Contrary to the assumptions of public health officials, Uganda's
emphasis on abstinence and fidelity resonated strongly with young
people. Consider the changes in premarital sex, which for young people
can shape their sexual behaviors--and health risks--well into adulthood.
From 1989 to 1995, researchers reported a drop in the premarital sex
rate among young men from 60 percent to 23 percent. Among females, the
number dropped from 53 percent to 16 percent.16 A UNAIDS report found
that among 15-year-old boys and girls, those reporting that they had
never had sex rose from about 20 percent to 50 percent over the same
period.17
Some
researchers admitted that the findings took them by surprise: Many
assumed that teenagers, driven by "raging hormones," would be immune to
abstinence messages.18 The Ugandan government not only rejected this
assumption, but made youth the primary target audience of its national
program.
Numerous studies lend support to the effectiveness of the ABC model in
changing sexual behaviors. A USAID evaluation found that Uganda
experienced changes in all three primary prevention behaviors:
abstinence and delay in sexual debut among youth, marital faithfulness
and partner reduction, and the use of condoms.19 A UNAIDS report--though
exaggerating the data on condom usage--nevertheless found "substantial
differences in sexual behavior in almost every aspect that was
investigated," including delayed sexual debut and fewer sexual relations
with non-regular partners.20
Another USAID study, conducted by epidemiologist Dr. Rand Stoneburner,
formerly with the Centers for Disease Control and Prevention, concluded
that Uganda's success "appears to have taken root from the behavior
changes motivated by this communication-based, community-level response
to the epidemic."21 The study expressly noted that "something of a large
magnitude took place" in terms of messages and changes in sexual
behavior among ordinary Ugandans.22
How
large a magnitude? Two final numbers suggest its significance. A 1995
survey found that 89 percent of Ugandan men had changed their sexual
behavior to avoid AIDS.23 The same was true for Ugandan women: At least
98 percent were reporting either abstinence or no sex partner outside
their regular partners.24 Jim Shelton, senior medical scientist in the
USAID Office of Population, observes:
What
happened in Uganda is that a lot of forces at one time were promoting
more responsible sexual behavior, so you get to a social norm, a tipping
point kind of thing. At some point all these messages, plus seeing more
people dying, get people to change their sexual behavior.25
Many
people are dying of AIDS in other African countries, of course, and at
even higher rates. Yet most of these other countries do not offer a
clear, unambiguous ABC prevention message. (Senegal does, and it is
Africa's other notable success story in AIDS.)26
Lesson 2: Abstinence and marital fidelity appear to be the most
important factors in preventing the spread of HIV.
The
Ugandan approach was directed at two major population groups: children
(and unmarried youth) and the rest of the population (mostly married).
The message for the former group was to postpone sexual activity until
they were older, preferably until they were married. For the remaining
majority, the main message was "zero-grazing." (In Uganda, it was common
for married men to seek out other sexual partners.)27 The strategy
appears to have worked: Research data suggest a causal link between
changes in sexual behavior and the drop in HIV prevalence.
Dr.
Elizabeth Madraa, an AIDS program manager in Uganda's Ministry of
Health, reported in a UNAIDS study that "the increased targeting of
youth groups has contributed to the decline of HIV incidence among the
age groups of 13-19 and 19-24 years."28 In the African Journal of AIDS
Research, researchers Daniel Low-Beer and Rand L. Stoneburner identified
a decrease in casual sex as the most significant variable. "The most
important factor in this decline is a decrease in non-regular partners
by 65 percent (1989-1995), and a contraction in sexual networks," they
wrote. "This has been shown in successive analyses of Ugandan
epidemiological and behavior data over time."29 Stoneburner presented
similar findings at a USAID technical meeting last year: The drop in HIV
incidence "suggests a preceding process of behavioral change to avoid
risk infection," he concluded. "In the case of Uganda, this behavioral
change primarily took the form of partner reduction."30
The
data are consistent with the findings of several studies involving
epidemiological modeling of HIV transmission. They indicate that the
single factor most likely to reduce HIV prevalence levels is a decrease
in the number of sexual partners.31 "Reduction in the number of sexual
partners was probably the single most important behavioral change that
resulted in prevalence decline," concludes Dr. Green. "Abstinence was
probably the second most important change."32
Some
claim that declining HIV prevalence is a mirage: So many people
succumbed to the disease, it is argued, that the number of AIDS deaths
simply dwarfed the number of new infections. Deaths from AIDS can lower
prevalence, but mostly in older age groups. It does not account for
prevalence decline among 15-19-year-olds, who simply are not old enough
to have become sick and died of the disease. The only reasonable
explanation for the drop in HIV rates among this population group--in a
culture with low rates of condom use--is a change in sexual behavior.
Although calling the link between the government's ABC program and HIV
reduction "not yet completely understood," a USAID report nevertheless
admitted that changes in the age of sexual debut, casual and commercial
sex trends, and partner reduction "all appear to have played key roles
in the continuing declines."33 The trend was observed across geographic
and demographic populations: "Uganda's falling HIV prevalence is likely
not due merely to measurement bias or a `natural die-off syndrome,' but
rather mainly to a number of behavioral changes that have been
identified in several surveys and qualitative studies."34
Taken
together, these studies strongly support the view that abstinence and
fidelity were the most important factors linked to the reduction in the
HIV/AIDS rate in Uganda.
Lesson 3: Condoms do not play the primary role in reducing HIV/AIDS
transmission.
Most
U.S. and foreign health organizations--including the USAID, Centers for
Disease Control, UNAIDS, and World Bank--focus on condom education and
distribution to combat AIDS. They assume that the real problem is a
"condom shortfall."35
This
was neither the assumption nor the strategy of the Uganda campaign. "We
are being told that only a thin piece of rubber stands between us and
the death of our continent," says Uganda President Yoweri Museveni.
"Condoms have a role to play as a means of protection, especially in
couples who are HIV-positive, but they cannot become the main means of
stemming the tide of AIDS."36
Under
Uganda's ABC approach, condoms were considered the last option, aimed
primarily at high-risk groups such as commercial sex workers unlikely to
change their sexual behaviors. The general population, however, mostly
rejected the condom option. Dr. Vinand Nantulya, an infectious disease
advisor to President Museveni and senior health advisor at the Global
Fund for AIDS, Tuberculosis and Malaria, summarized, "Ugandans really
never took to condoms."37
Although there is some evidence that condom use has increased among
those who are sexually active,38 several studies conducted during the
previous decade strongly suggest that condoms played only a marginal
role in lowering Uganda's HIV/AIDS rate:
-
The condom usage
rate in Uganda is only average for Africa.39
-
Even after
distribution campaigns, condom usage remains stable at low rates.40
-
Of the condoms
distributed to high-risk groups in Uganda, 91 percent went unused.41
-
In one rural
population-based cohort, there was "no overall protective effect
against HIV acquisition in women who reported condom use."42
Condoms may be somewhat effective when targeted at high-risk groups such
as commercial sex workers and their clients. However, there is no
credible evidence that condom promotion is ultimately the best way to
protect these groups from AIDS.
First,
the overall effectiveness of condoms in preventing HIV/AIDS transmission
remains hotly debated. A meta-analysis published in the Cochrane Review
suggests that, even when condoms are used consistently, their
effectiveness is only about 80 percent.43 A draft report for UNAIDS puts
the failure rate of condoms at about 10 percent (meaning that something
goes wrong in about 10 percent of all cases when condoms are used). The
report's lead author, Norman Hearst, a professor at the University of
California at San Francisco, says that policymakers should be talking
about "safer sex," not safe sex, when speaking of condoms.44
Second, regular use of condoms may delay--but not prevent--HIV
infection. This approach, known as "risk reduction," is ultimately
fatalistic; it holds out little hope that people can abandon destructive
behaviors. It also rests on a deeply flawed assumption: that people
engaged in dangerous and self-destructive lifestyles--making highly
irrational choices--will somehow act rationally once they are given a
condom. The high-risk behaviors of those in the sex industry almost
guarantee that they eventually will contract HIV or other
life-threatening diseases. A truly humane approach would link the
targeted distribution of condoms with programs that rescue sex workers
from the streets by providing education, job training, family
assistance, and exposure to supportive faith communities.45
Insisting on condoms as the primary strategy to reduce AIDS not only
overlooks the lessons of Uganda and the failure rate of condoms, but
also ignores how the disease is usually transmitted. When the AIDS virus
is contracted widely throughout a society--as it is in much of
Africa--condoms appear to be the least effective means to control it. A
UNAIDS report makes the point clearly: "There are no definite examples
yet of generalized epidemics that have been turned back by prevention
programs based primarily on condom promotion."46
Harvard's Dr. Green, a supporter of condom distribution programs before
1993, now agrees: "It must be acknowledged that program emphasis on
condom provision and promotion alone does not seem to have paid off."47
This
helps explain why countries with the highest levels of condom
availability--Zimbabwe, Botswana, South Africa, and Kenya--still have
the world's highest HIV prevalence rates.48 It is essential that the
principles of the ABC program be applied in the right order: abstinence,
fidelity, and then condoms as a last resort. "Kids are willing and able
to abstain from sex," says Dr. Anne Peterson, USAID director of global
health. "Condoms play a role. They are better than nothing, but the core
of Uganda's success story is big A, big B and little C."49
Lesson 4: Religious organizations are crucial participants in the fight
against AIDS.
Participation in Uganda's AIDS campaign by faith-based organizations (FBOs)
across Christian, Muslim, and Jewish traditions appears to have been a
crucial part of the effort's success. Faith-based organizations were
involved from the beginning of the national response and were considered
adept at promoting abstinence and faithfulness.
Churches, mosques, and other houses of worship provide an important
social infrastructure, especially in rural areas, and congregations
generally trust and respect their religious leaders and do not perceive
them as politically motivated.50 One UNAIDS report concluded that "it is
crucial to work at the community level to personalize social norms such
as mutual fidelity and the moral responsibility not to endanger
others."51
National religious groups, such as the Islamic Medical Association of
Uganda (IMAU) and the Anglican Church Human Services Prevention Program,
mounted serious education campaigns.52 The IMAU, for example, worked in
rural Muslim communities, training local religious and community
leaders. Leaders from about 850 mosques trained 6,800 volunteers to
assist in its education campaign. The Protestant Church of Uganda
organized a workshop for bishops and other religious leaders and
launched AIDS education projects in numerous dioceses. The Catholic
Church and its affiliated hospitals designed AIDS home-care programs and
programs for AIDS widows and orphans while promoting marital fidelity
and abstinence.
As
early as 1993, more than 1,500 NGOs were addressing HIV/AIDS in Uganda.
Local church-based organizations have led the prevention and treatment
efforts among NGOs operating in the country. "Religious groups form an
essential part, if not the bulk, of such organizations," says Dr. Jeremy
Liebowitz of the Health, Economics, and HIV/AIDS Research Division of
the University of Natal.53
Negotiating Differences
Although government and religious groups did not always share the same
priorities or approaches, they appear to have worked side by side
wherever possible. The three chairmen of the Uganda AIDS Commission have
included an Anglican and a Catholic bishop.
A
hot-button issue for some religious groups was condom distribution, but
it was handled through consultation--not government fiat. The IMAU, for
example, held workshops for imams on the topic. By the end of the
process, they reached a compromise consistent with their religious
beliefs, which became part of their education program.54 Says Liebowitz:
"Religious leaders and government officials seem to have pursued their
approach on parallel tracks rather than as opponents."55
Church-state cooperation was evident from the start of the crisis, when
religious leaders from various faith traditions formed the
Inter-Religious Council of Uganda (IRCU) to design a unified response.
The IRCU coordinates a comprehensive, national, church-based approach
that includes:
-
Teaching
abstinence and fidelity,
-
Publishing
educational and promotional materials,
-
Providing home
care and counseling,
-
Operating clinics
and hospitals,
-
Providing
spiritual comfort to the victims of AIDS, and
-
Promoting
discussion and openness.
Removing Stigma
Religious bodies are sometimes accused of stigmatizing people with AIDS.
In Uganda, the reality was exactly the reverse: The religious
community's sober approach to the AIDS threat helped to greatly reduce
the stigma attached to the disease while challenging people to adopt
safer sexual behaviors.
When
the Reverend Gideon Byamugisha, a nationally known religious leader,
learned that he was HIV positive, he went public. His message was not
one of condemnation, but an appeal to act responsibly. Religious
communities have led efforts to care for those suffering with HIV/AIDS,
offering counseling, palliative care, and home visitation. They have
reached out to vulnerable children orphaned because of the disease.
Reinforcing the government's educational efforts, faith communities have
helped promote a change in sexual mores: a culture in which abstinence
and marital fidelity are held out as realistic and responsible lifestyle
decisions. "The Christian church spearheaded AIDS care services in
Uganda," observes Dr. Elizabeth Madraa, program manager of the STD/AIDS
Control Program of Uganda's Ministry of Health. "The success of Ugandan
prevention efforts would not have occurred without intensive
participation and involvement of community leaders."56
Empowering Women
By
leading through example and teaching the values of abstinence and
fidelity, religious groups helped instigate positive changes in cultural
attitudes toward women. Critics have dismissed morality-based prevention
programs, in part because they assume that African women lack the social
status to make independent decisions about their sexual behavior.
But
the messages of sexual responsibility carried by governmental and
non-governmental organizations, including religious groups, have
strongly supported Ugandan women. Indeed, the empowerment of women has
been a deliberate government policy since 1986. A recent multi-country
survey found that Ugandan women ranked first among all African nations
in their ability to refuse unwanted sex or insist upon condom use.57
Defending Religious Freedom
The
U.S. Congress has specifically noted that faith-based organizations "are
making an important contribution to HIV prevention and AIDS treatment
programs around the world." The U.S. Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Act includes language that protects the
religious conscience of these organizations as they partner with
government to help people in need. As the legislation stipulates:
[FBOs]
shall not be required, as a condition of receiving the assistance, to
endorse or utilize a multisectoral approach to com-bating HIV/AIDS, or
to endorse, utilize, or participate in a prevention method or treatment
program to which the org-anization has a religious or moral ob-jection.
Such
religious liberty protections are non-negotiable: The Catholic Church,
for example, cares for one in every four AIDS patients worldwide, yet
rejects strategies based on condom distribution for religious reasons.
Faith-based organizations such as World Relief, the Islamic Medical
Association of Uganda, and American Jewish World Service are all
important players in the overall response to the global AIDS crisis.
These
and other FBOs, often working in difficult or dangerous circumstances,
are providing significant help to those suffering abroad. It is
essential that the Bush Administration and Congress give FBOs a major
role in combating the AIDS pandemic while respecting their independence
and religious missions.
Can Uganda's ABC Model be Exported?
President George W. Bush's attention to the AIDS crisis in Africa,
emphasis on FBOs in fighting social ills, and recognition of the
cultural roots of the AIDS pandemic have helped create a policy
environment in which Uganda's success could be replicated in other
nations ravaged by the disease. The ABC approach was designed and
developed by Ugandans and is, in a sense, unique. But is it a basis for
global HIV prevention policy?
"There
are common elements which characterized all the successes against HIV,
which have been transferable in widely different situations," explain
researchers Low-Beer and Stoneburner. All the major success stories in
HIV prevention share the Ugandan emphasis on delivering clear cultural
messages about the disease and the importance of behavior change to
avoid it.
Senegal, Thailand, Zambia, Jamaica, the Philippines, and the Dominican
Republic are already witnessing success by embracing at least some of
the principles of the ABC program. A UNAIDS multi-center study in four
African cities found that fewer sexual partners and delayed sexual debut
were associated with lower levels of HIV prevalence--more so than any
other behavior change.58 The Uganda strategy, researchers conclude,
strongly suggests that a "social vaccine" against HIV/AIDS can be
developed--one as potent as a medical vaccine.59
The
Philippines
The
Philippines has adopted a campaign that emphasizes responsible sexual
behavior and enlists the religious community as a key partner. A
significant percentage of the population works outside the country,
which contributes to higher rates of infection as workers often return
carrying the disease.
The
national infection rate, however, has held steady at about 0.01 percent,
despite very low condom usage in the general population. Why? A USAID
study found that the population has low levels of multi-partner sexual
activity and high levels of abstinence, especially among youth.
According to the report, "the Catholic Church must be credited with
influencing sexual behavior."60
A
Mixed Bag in Brazil
Those
who are skeptical of Uganda's success invoke Brazil as the model
response to the AIDS pandemic. To its credit, Brazil has taken its AIDS
crisis seriously. The government has greatly increased public awareness
of the disease and moved aggressively to treat those already
infected--an essential task in the fight against AIDS.
However, Brazil's experience is of limited value to the much poorer
nations of Africa. The country's strict emphasis on treatment therapies
and condom distribution--and its inattention to destructive
lifestyles--is leaving large numbers of Brazilians vulnerable to the
disease. The prevalence of HIV in Brazil is still higher than in most
Latin American and Caribbean countries. For high-risk groups, the HIV
prevalence is an astonishing 42 percent, a level comparable to countries
such as Zimbabwe and Botswana.61 In short, Brazil does not offer
policymakers the most effective model for HIV/AIDS prevention.
The
New Cultural Imperialists
Many
U.S. and international public health officials consider the promotion of
"behavior modification" a kind of "cultural imperialism." They argue
that it is either arrogant or ineffective to encourage foreign cultures
to adopt "traditional" or "conservative" sexual lifestyles.
How
well the Ugandan approach can be implemented in other countries remains
to be seen. Not all governments are prepared to deliver a unified
prevention message. The low economic and social status of women in many
underdeveloped countries can make it difficult to achieve a safer sexual
lifestyle. Moreover, the strength of civil society varies greatly from
nation to nation: Religious communities must be trained to face the AIDS
issue soberly, have extensive social networks, and be able to exercise a
measure of cultural influence. That will not be the case in every
country struggling with the disease.
Nevertheless, imposing the programs endorsed in San Francisco and New
York--especially given their problematic results in reducing
HIV/AIDS--on traditional, religious societies makes little sense. The
dominant prevention paradigm of massive condom distribution and access
to anti-retroviral drugs simply disregards the priorities and resources
of many of the world's poorest nations. Moreover, it ignores the results
accomplished in Uganda with its emphasis on behavior change. "Unlike the
Ugandans themselves, foreign researchers had been surprisingly reluctant
to highlight the precise changes in basic sexual behavior," one study
concludes. "The neglect and misanalysis of the data on Uganda for almost
a decade...seems a serious issue in a situation of severe epidemic."62
Now is
the time to end such neglect. The Ugandan government designed the ABC
model as the strategy most likely to be endorsed by the nation's general
population and its civic and religious groups. It was an appeal to the
country's older tradition of marriage and fidelity; it did not rely on
either advice or technology from Western experts.
There
is no reason to assume that a similar approach would fail in other
nations battling HIV/AIDS.63 The real cultural imperialists are those
who would impose on non-Western cultures a uniquely Western, medicalized
approach to fighting AIDS.
Roadblocks to Reform
There
are, nevertheless, several serious obstacles to the President's AIDS
initiative. Any one of them could undermine the plan. Together, they
could transform it into a multibillion-dollar boondoggle.
-
Most African
countries lack the health care infrastructure required to address AIDS
and other deadly diseases effectively.
The public health
care system now reaches only about 10 percent to 20 percent of the
people in Africa.64 HIV is an especially drug-resistant virus, and
sound methodologies and therapies must be imposed in nations now
lacking the resources.
Access
to anti-retroviral drugs, effective testing programs, the establishment
of clinics in rural areas, and expertise in endocrinology, virology, and
pharmacology are all necessary parts of an intensely complex treatment
regimen. This will require a carefully designed package of foreign
investment and expertise. However, according to the World Health
Organization, the track records of Africa's ministries of public health
are so abysmal that the billions of dollars in foreign aid to date has
made little difference.65
-
African leaders
have been slow to admit the seriousness of the AIDS crisis and develop
treatment strategies to confront it.
Some have even
dismissed AIDS as a racist conspiracy plot. President Thabo Mbeki of
South Africa claimed in 1999 that AIDS is not caused by HIV but by
poverty--a statement he has since abandoned. Many African governments
are wholly unaccountable, either to international organizations or to
their own citizens. Without reforms, international assistance could
easily be squandered through corruption and mismanagement.
"President Bush's initiative will only work if African governments are
serious about tackling the AIDS epidemic, and are willing to undertake
their own domestic initiatives to combat the disease," economist George
B. N. Ayittey recently told the Presidential Advisory Council on
HIV/AIDS. "Absent meaningful reform, the Bush initiative will induce
another cycle of aid dependency."66
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Many health care
organizations and activists continue to promote AIDS prevention
strategies that are deeply problematic.
In July 2002, the Global HIV Prevention Working Group, convened by the
Bill & Melinda Gates Foundation and the Henry J. Kaiser Family
Foundation, issued a "blueprint for action" that emphasizes sex
education, condom distribution, needle-exchange programs, and better
access to anti-retroviral drugs. The example of Uganda's success,
though mentioned briefly, was mischaracterized as an "extensive condom
promotion" campaign--without a word about changes in sexual
behavior.67
Representative Barbara Lee (D-CA), chairman of the Congressional Black
Caucus (CBC) Task Force on Global HIV/AIDS, has argued that it is unwise
for the United States to prioritize any approach over another: "We have
to support the use of condoms as a realistic means to reduce the spread
of HIV just as equally as we support the promotion of abstinence and
being faithful."68 In the view of Adrienne Germain, president of the
International Women's Health Coalition, any approach that de-emphasizes
condom distribution "basically condemns people to death by H.I.V./AIDS.
And we're talking about tens of millions of people."69 And Paolo
Teizeria, director of Brazil's AIDS program, told participants at an
international AIDS conference that "millions and millions of young
people are having sexual relations. We cannot talk about abstinence.
It's not real."70
Such
views dominate international public health organizations--the groups
that would likely be deeply involved in any HIV/AIDS programs for
underdeveloped countries. The President's AIDS initiative will fail if
it comes under the influence of public health bureaucrats who continue
to ignore the most effective HIV/AIDS prevention programs.
What Needs to be Done
Congress has authorized up to $3 billion per year for the next five
years to combat AIDS. The legislation, signed by the President,
authorizes the following distribution of funds: 55 percent for treatment
of individuals with HIV/AIDS; 15 percent for palliative care; 10 percent
for orphans and vulnerable children; and 20 percent for prevention, of
which at least 33 percent is specifically reserved for abstinence
programs.
An
argument can be made for a significant multinational investment in
HIV/AIDS treatment programs for Africa. Most of the continent lacks the
health care infrastructure required to address AIDS and other deadly
diseases effectively. In addition, treatment of those either afflicted
or at risk of infection is only part of the solution: The AIDS pandemic
has left behind a staggering number of orphans and at-risk children--11
million orphaned children in Africa alone.
This
demands an international response to prevent millions of families from
slipping into poverty and despair. A careful investment in community and
faith-based groups assisting this population would be money well spent.
Symptoms Versus Causes
However, the Administration and Congress are under tremendous pressure
to fund programs that treat only the symptoms of the disease and not the
underlying causes of its pandemic spread--from reckless sexual behavior
to illicit drug use. That approach can produce complacency among at-risk
populations, as the recent increase in HIV/AIDS among American gay men
suggests.
"I
think the most compelling reason [for the increase in AIDS] is that
people aren't scared anymore," says Harold Jaffe, director of the
National Center for HIV at the Centers for Disease Control.71 In
contrast, the first thing that Uganda did was to introduce a healthy
dose of fear about contracting AIDS.
An
important way to counter a drift toward complacency is to increase the
portion of prevention money devoted to abstinence programs. First, the
33 percent figure simply fails to reflect what is known about the most
effective prevention models. Second, it remains unclear whether even
that sum would go to effective abstinence programs.
Both
the intent and the letter of the law allow for a higher amount: At least
75 percent of prevention funding should be targeted specifically to
programs promoting abstinence until marriage and marital fidelity (or
partner reduction). As Uganda's success demonstrates, this could do the
most to cut HIV transmission rates and save lives. Good public health
policy, not ideology, must drive this process.
If the
President's global AIDS initiative is to succeed, he and the Congress
should pay careful attention to the success of the Uganda model.
Specifically, they should:
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Endorse effective
AIDS prevention policy that emphasizes abstinence and marital
fidelity.
Most international AIDS "prevention" and "behavior change" programs do
not protect individuals from the disease because they fail to
discourage the high-risk sexual behaviors that invite its spread.
These approaches, which typically concentrate on condom distribution,
are dramatically failing to combat AIDS and save lives.
Uganda
demonstrates that it is possible to bring about widespread changes in
risky sexual behaviors and significantly reduce HIV rates. Indeed,
reductions in casual sex have been linked to the major successes in HIV
prevention in other countries, such as Senegal, Zambia, and the
Philippines.72
The
President and Congress should insist that America's global AIDS policy
reflect the evidence of these successes: They should direct at least 75
percent of U.S. funding for prevention toward abstinence-only and
fidelity-based education programs. This would signal a profound shift in
U.S AIDS policy--and would be met with intense opposition. Nevertheless,
unless much greater attention is devoted to preventing the transmission
of HIV/AIDS, the disease will continue to ravage entire societies.
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Support rescue and
recovery programs for high-risk groups.
Without aggressive intervention, individuals such as commercial sex
workers and intravenous drug users are unlikely to give up lifestyles
that regularly expose them to AIDS. Although condom use among sex
workers has increased in Uganda and perhaps slowed transmission of
HIV, this is no argument for relying primarily on condom distribution.
Likewise, advocates of needle-exchange programs claim that they
prevent addicts from contracting AIDS from sharing dirty syringes.
Such "risk reduction" approaches may delay the onset of HIV infection,
but they do nothing to truly protect people from the virus.73
Programs that legitimize the commercial sex industry and the illicit
drug culture amount to "death on the installment plan" for those engaged
in these behaviors. As public health policy, they remain deeply flawed
and morally objectionable. A more humane approach is to support programs
that rescue women from the sex-trade industry and help addicts break
free of addiction. Condom promotion might be part of such programs, but
the emphasis should be on job training, education, family assistance,
rehabilitation, and exposure to supportive faith communities--all with
the aim of helping individuals abandon destructive lifestyles.
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Empower NGOs while
protecting their civic and religious freedom.
Community and
faith-based organizations that uphold the principles of the ABC model
should be given the lead in implementing HIV/AIDS programs in
developing nations. These organizations, working at the local level
with community and religious leaders, have the knowledge and
experience to design the most effective strategies. Wherever possible,
the Administration and Congress must bypass corrupt and inefficient
governments and distribute AIDS money directly to NGOs or intermediary
organizations.
Furthermore, all NGOs--secular and religious--should be eligible for
federal support without compromising their moral and religious beliefs.
No group should be excluded because of religious objections to condom
distribution. In fact, empowering NGOs would mean upholding previously
established U.S. AIDS policy. For example, in 1992, USAID gave about
$350,000 each to the three major religious groups working in Uganda:
Anglican, Catholic, and Muslim. Partnering with the national government,
they designed programs consistent with their religious values.74 The
Bush White House says it supports "additional provisions" to protect the
FBOs against government requirements "if such activities violate a tenet
of their faith."
The
U.S. Department of Labor recently announced the availability of $1
million in grants to community and faith-based organizations in Uganda
to "[i]ncrease knowledge of HIV/AIDS prevention methods among Ugandan
men and women as a first step to changing sexual behavior."75 That is
the right approach to fighting the disease: a church-state partnership
that focuses on effective prevention and allows the FBOs to do the job
in a way that affirms their religious values. The Administration and
Congress must uphold this principle of civil and religious liberty,
which coincides with sound public health policy.
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Sharply limit U.S.
contributions to international AIDS organizations that fail to support
the most effective programs.
There is little
evidence that international health institutions have absorbed the
medical and moral lessons of Uganda. "As late as 2002," observes
Daniel Low-Beer, formerly with the World Health Organization, "all the
major organizations denied the role of declines in casual sex and
partner reduction in Uganda."76 There are encouraging signs, however,
that some officials at the Global Fund for AIDS77 are willing to
enlist faith-based organizations involved in sound prevention
programs.78 The appointment of Dr. Vinand Nantulya, an advisor to
Ugandan President Museveni, as a senior health advisor to the agency,
is also a promising step.
Nevertheless, the Global Fund--like UNAIDS and WHO--continues to devote
much of its resources to the least effective means of combating
HIV/AIDS. Equally troubling, these agencies suffer under complex and
costly bureaucracies. A recent study shows that the average salary for
Global Fund employees was $174,603 (a sum greater than the salaries of
most heads of state).79
Thus,
the U.S. contribution to the Geneva-based agency should be capped at
$200 million per year until it reforms its policies and programs.
Moreover, the U.S. contribution should be earmarked for effective
treatment programs at the local level. To that end, Congress may approve
bilateral assistance to governments with sound AIDS prevention
strategies, but the majority of U.S aid should be directed to NGOs and
private-sector companies already effectively fighting the disease.
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Insist that the
Global AIDS Coordinator fully implement the ABC prevention model.
President Bush recently nominated Randall Tobias, former chief
executive officer of Eli Lilly, to serve as Global AIDS Coordinator.
In this position, Mr. Tobias will report directly to the President and
oversee the appropriated funds.
The
office of the Global AIDS Coordinator should have the authority to
reject programs that flatly contradict the President's AIDS agenda and
its emphasis on effective prevention. It is essential that Mr. Tobias
fully endorse the ABC approach to confronting HIV/AIDS and work to
implement it through all federal agencies involved in fighting the
disease.
Not
much is known about the retired Indianapolis pharmaceutical executive,
but the director of an AIDS support group in Indianapolis claims that
Mr. Tobias is "too practical" to support an abstinence-only approach to
AIDS prevention.80 During the Senate confirmation process, Mr. Tobias
must demonstrate his commitment to existing law and to the principles
and the science guiding the President's AIDS policy.
Conclusion
The
Bush Administration's AIDS initiative is a bold and ambitious plan to
tackle a pandemic that is ravaging the lives of millions of people
across Africa and the Caribbean. The White House seems to understand
that the favorite solution of Western public health elites--a "condom
airlift" for the continent--would be a medical and moral disaster.
President Bush told President Museveni during his recent Africa trip:
"You have shown the world what is possible in terms of reducing
infection rates." As the Administration and Congress implement America's
new AIDS initiative, it is vital that they use the example of Uganda as
a yardstick for effective policy.
There
are tremendous pressures--political and economic--to export deeply
flawed AIDS strategies to vulnerable populations. They must be resisted.
To do otherwise is to allow interest groups and ideology to trump sound
public health policies. The time is ripe for a new, effective approach.
Actor
and AIDS activist Harvey Fierstein recently lamented that many of his
friends were again involved in high-risk lifestyles, apparently
unconcerned about contracting AIDS. "HIV is an almost completely
avoidable infection. You need to be compliant in some very specific
behaviors to be at risk," he wrote in The New York Times. "I am calling
us to take back our lives and culture and stop spreading the virus."81
It was
a summons that could have been issued by the Ugandan president--and was,
in fact, the substance of his own appeal. "We made it our highest
priority to convince our people to return to their traditional values of
chastity and faithfulness or, failing that, to use condoms," Museveni
told drug company executives during a June meeting in Washington. "The
alternative was decimation."82
Critics of the Administration's AIDS policy for Africa should meditate
long and hard on that alternative.
Joseph
Loconte is the William E. Simon Fellow in Religion and a Free Society at
The Heritage Foundation and the author of Seducing the Samaritan: How
Government Contracts Are Reshaping Social Services (Boston: The Pioneer
Institute, 1997). John D. Pitts, Jr., a former intern at The Heritage
Foundation, served as a research assistant for this paper.
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